an interview with ina may gaskin
sara wickham

This article was originally published in
The Practising Midwife, January 2002.
Republished with permission.


Ina May Gaskin has been described as “the most famous midwife in the world”. A self-taught 'lay' midwife, she has practised midwifery for over thirty years, written books about her experiences and lectured all over the world. She is the immediate past President of the Midwives Alliance of North America and recently visited the UK, where she gave the following interview.


Ina May, you've been a midwife for thirty years this year. How has midwifery changed in the thirty years that you've been practising?

For me, in the US, midwifery didn't exist thirty years ago. And so many women didn't even know there was such a thing. Of course, there were a few nurse-midwives, but they hadn't got their message out. But then this sort of eruption happened, of people who just suddenly became midwives overnight, because their friends just demanded, “stay home with me”. These midwives got their skills and knowledge base out of books, from midwives who were trained in Scandinavia, Britain, other countries. Sometimes there was a kindly doctor - of course, women need other women - but they would help. And there were hippy doctors; residents, SHOs, doctors-in-training who became part of the movement too, they came out and taught us things, things to look out for.

People expect there will be midwives now, a good section of the people anyway. Just under ten percent of the population have a midwife-attended birth in the US now, it doesn't sound like much, but that's up from nothing. A lot has been done there, and we have a whole generation of people born at home, and of course they have their effect too. That makes it stronger, so we've got a little hardy plant that's starting to grow. And we've certainly helped the growth of nurse-midwifery because all those people who empowered the home birth movement made the hospitals have to try to keep people in. That swelled the ranks of the nurse-midwives. There were a lot of people who didn't want to be a midwife outside of the system, they saw the need for midwives in the system.

There's still not an awareness in the US that a national health insurance system is a necessary component in changing the demograpy of birth attendants. For many years we've had a huge oversupply of obstetrician-gynecologists, of doctors attending births. They might not actually be there during labour but they swoop in at the last minute, catch the baby and take all the credit. And then we have a large number of 'labour and delivery' nurses that take the slots which in other countries are filled by midwives. These professions have their own need to remain there. So how do you change these demographics? You can't just let the system do it for you or you continue to have no midwives.

Are there any differences in the women's labours and births on The Farm today then when you started practising midwifery there?

Well, yes. In the beginning, I think probably because we started out giving birth in school buses and trucks, very small places, people didn't stand up much. They didn't kneel or get upright very much, it was just physically hard to do it. And I think the fact that photographs in those days showed women in those positions meant that women went into those positions. I did it myself. I don't remember having an urge to get up. I know I prowled around some in the early part of labour, and I know when I got fully dilated I had to stand up and I had to move the baby down well, but then sitting down to let the baby come out was pretty common among us. A lot of us used to do that.

Then there were some exceptions, we learned to attend birth on all fours, and we certainly used the all-fours manouvre for babies whose shoulders were stuck, but not everybody spontaneously went to that position. Now more and more they're doing that. Certainly the younger women, those who were born at home, born at The Farm, they're just wild! We have to chase them around, keep up with them. You never know where they're going to give birth, on the stairs, in the bathtub, sitting on the toilet, sitting on the floor right next to the toilet, they're all over the place, sometimes outside! They're quicker too, so I'd say that was the big change.

Can you identify one moment in your midwifery career which stands out above all others?

I'd have to say that night in the parking lot at Northwestern (University, where Ina May attended her first birth). If it had gone differently, my life would have been different. The fact that she had such a quick, beautiful, easy birth, opened up a whole huge vista before me, I became very excited… Here I was, just thirty years old, I having wondered for a long time what I would do when I grew up - and suddenly I knew. It was that “in the bones” feeling of it. I'd have to say that was the moment, because that made everything else possible.

You clearly have an incredible passion for midwifery. What is it about midwifery that you love the most?

I think it's because I spent so much time as a kid feeling cheated by being female, because I saw that this was not the powerful sex. And how could that happen?! Because (laughing) I wanted power! I had a brother who was two years older than me and all the women in my family just sort of accommodated men. I mean, these women were strong in their way, but I saw that it was a man's world. Then when I began to get older and become reconciled to being female, I thought about birth. I think Grantly Dick-Read's book was significant in my thinking because I read that when I was sixteen. All of this was in my mind and I saw that it took some sort of gathering of courage to go ahead and have a baby and I thought, “Ok, maybe there's some sort of power in that”. And that little hunch certainly turned out to be true.

What are you passionate about right now?

I've been doing some very patient work over many years, just collecting data from the births I've attended and comparing and studying how we ever got to the point we are at. I think I understand quite a few things now, and I've discovered some things that I really was naïve about, and I think people in the US and other countries are naïve about it too. This has to do with the dread subject of maternal death. Of course, the ranking of the US in the world in nothing to be proud of, we're only 21st. But even then we're only talking about reported deaths and the Centre for Disease Control (CDC) admits it's likely they are collecting as few as a third of the maternal deaths that actually occur. And they're only counting til six weeks after the end of pregnancy, so they're missing those that happened between six weeks and a year, that could be an awful lot of deaths. In a for-profit system there's hardly much incentive to report maternal deaths, there's no audit, it's really a poor system to put any stock in. It's a wildly optimistic guess. Of course, they don't state the rate for the US and then put in parentheses - (wildly optimistic guess)!

Also you have in the US an obstetric profession that's used to making decisions which aren't based on evidence and not informing women that they are making some wholesale change. Women just assume that because they're doing it, it's alright. I'm looking at the use of misoprostil for cervical ripening and labour induction, I know of at least four or five maternal deaths associated with that.

Then there's a new way of suturing the uterus after cesarean that seems to have some dangers associated with it. That's where they are stitching the uterus in one layer instead of two, I think you call that mass closure. Two layers have been used for 75 years. It's pretty plain to me that this change did not come about because the other way was found to be wanting, it's more a matter that money can be saved by stitching in one layer. But I know of three women who have died from it, two from placenta percreta and one from bleeding around the wound that wasn't detected until it was too late. There's a Montreal study - the abstract appeared in the Journal of Obstetrics and Gynecology supplement in January 2000. That involved 1650 women and the people who had one layer closure showed five times the rupture rate in subsequent births. They did control for induction in both groups, that was factored in.

Frustrated by all of this, and haunted by the number of women I've found out about who have died, and also about the fact that the US maternal death rate has not gone down since 1982, and may in fact be going up, we have a problem. I just want to warn people not to follow the US obstetrical trends and I'm mindful that there may be some maternal deaths associated with these trends that there may not be a way to know about.

So, inspired by the AIDS quilt, I've thought up a project that maybe could make a difference here. I've decided to make, or ask somebody else to make a quilt piece to commemorate each women who has died of causes directly related to pregnancy or birth since 1982. We are counting the full one-year period so that we'll be more in-synch with the rest of the world. This might be thousands of women. Twenty are now completed. I just continue to work on it, I've been working on this since February 2001 and I see that it has power.

There are people within the CDC who were very nice, they had me display it at the National Summit for Safe Motherhood in September, that's the first meeting of that kind we've had in the US. They're not holding me at arm's length and I'm very encouraged by that. A lot of my focus in 2002 is travelling around the US, visiting women's groups to get the names of the women - they have to come from families and friends because people who work at the hospitals are not permitted to divulge those kinds of details.

You clearly have an international perspective on midwifery. From that perspective, what do you see about the current situation of midwifery in the UK?

I've been watching you all here for about twenty years. Morale was very high twenty years ago, you were getting some things done, there was a lot of excitement. Then there was excitement about Changing Childbirth, the Winterton Report, having a Member of Parliament, Audrey Wise, who was really on your side. I know it had to be a huge loss, her recent death.

I think also I might have an idea of what would help you get back up on your feet again, and that would be to look at New Zealand. That helped me, I've been watching them for twenty years too and they are way ahead of where they were twenty years ago. They're independent now, and that's something that midwives in all countries should aspire to. They've actually pulled it off. They got their early inspiration from a US organisation called NAPSAC (National Association of Parents and Professionals for Safe Alternatives in Childbearing). They still publish good work (see www.napsac.org).

Joan Donnelly - the key figure in the early days who midwifed the midwifery movement in New Zealand - borrowed a lot of stuff from NAPSAC. When she and only two other midwives attended all of the home births in the country, they knew that they needed some soil to grow, and saw that as the home birth mothers. So they got those mothers involved and they got them passionate. Joan Donnelly has got a brilliant strategic mind, she's a first-class politician and also a great midwife. She had the loyalty of the women, understood the midwives' needs and yet she's also a broad thinker, quite a visionary. She brought those mothers and midwives together, they had home birth associations all over New Zealand before they had the New Zealand College of Midwives, they only formed that around 1990.

The New Zealand midwives were able to win their autonomy with doing political work, writing letters to the media, witty letters, they took on all these fights and won so much, they even had the cartoonists on their side, they had their own cartoonist doing work. They won their independence, their autonony, got out from under nursing around 1990. Now they've had ten years to show that, because of doing this, their perinatal mortality went down. It's hard to counter that argument.

If you didn't have The Farm and were working in a situation where you were surrounded by the constraints which British midwives work within, how would you work within or try to change the system?

I'll be honest and say it's a little bit hard to imagine myself working within a system, because I've been so steadfastly not doing that for thirty years! I've watched some of my friends do things effectively, they get to know everybody and stay connected to all the groups. I would hang around independent midwives and try to observe them, I would try to bring my friends who worked in the same hospital, including my boss. I would associate and socialise with those people who didn't agree with me - try to have social time with them and make friends with them. I would keep my data, get interested in research. But I think you have to not just hang out with those people who already agree with you. Introduce people who are maybe far apart and see if we can pull some of this entrenched “we must keep it this way” stuff into free-thinking things.

I'd be grateful for small things. Work gently and patiently to make things better for women. I would do what I could to get these home birth associations going, that can be really powerful. I would probably do yoga, knit and work in my garden to try to recover from the hard days! Take study days. And think success! I can't wait til you guys really get some big time changes going, changes that satisfy you!

If you could tell all student midwives one thing, what would it be?

Never stop learning; keep your mind open. Women have so much to teach us, and I don't think we can ever come to the end of that.


Ina May's new book, which may be titled “Ina May's Birth Book”, will be published Summer 2003. She is planning to come to the UK to do a book tour. She is also writing two other books and continues to attend births. For more details on the quilt project, see www.rememberthemothers.com For information on visiting The Farm and attending a midwifery workshop with other British midwives, click here.